37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 614915 |
Time | |
Date | 200404 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : abq.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 15 |
ASRS Report | 614915 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : unqualified personnel performance deficiency : testing performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MAINT MANUAL |
Narrative:
On apr-wed-04, aircraft was on a revenue flight. The pilot reported binding in the elevator system in the down direction. ZZZ1 maintenance could not isolate the problem so the aircraft was flown to ZZZ by a test crew. The test crew also reported binding in elevator system. I was assigned to work the aircraft on apr-tue-04, after troubleshooting for several hours I found the l-h elevator down control cable misrouted over the top of a frame at station 1134 by the APU compartment. The cable had cut through the frame past the l-angle more than 1/8 inch deep and the cable was starting to fray, failure of the cable or farther binding by cutting into the frame could have caused complete loss of the l-h elevator. The aircraft had just come out of a heavy overhaul by an outside vendor on jan-wed-04. This is not the first time we have seen such poor quality work come from these contracted operations and provides a perfect example of why these operations need much greater oversight by the FAA & NTSB. They are producing poor quality work with disastrous potential. Callback conversation with reporter revealed the following information: the reporter stated after troubleshooting for several hours, the left elevator down cable was found misrouted over the top of a frame at station 1134 at the auxiliary power unit compartment. The reporter said the cable .125 inch diameter, had cut more than one eighth inch deep into the frame and 'left' angle and the cable was beginning to fray. The reporter stated the tension on the cable was three times required maintenance manual limits. The reporter said the fact the tension was way out of limits should have alerted the persons installing the cable of something seriously wrong. The reporter stated this was one of many heavy maintenance jobs done by contract maintenance that was accomplished with poor quality work.
Original NASA ASRS Text
Title: A B737-300 RPTED BINDING IN THE ELEVATOR SYSTEM. FLT TEST CREW ALSO RPTED BINDING CAUSED BY ELEVATOR CABLE MISROUTED.
Narrative: ON APR-WED-04, ACFT WAS ON A REVENUE FLT. THE PLT RPTED BINDING IN THE ELEVATOR SYS IN THE DOWN DIRECTION. ZZZ1 MAINT COULD NOT ISOLATE THE PROB SO THE ACFT WAS FLOWN TO ZZZ BY A TEST CREW. THE TEST CREW ALSO RPTED BINDING IN ELEVATOR SYS. I WAS ASSIGNED TO WORK THE ACFT ON APR-TUE-04, AFTER TROUBLESHOOTING FOR SEVERAL HOURS I FOUND THE L-H ELEVATOR DOWN CTL CABLE MISROUTED OVER THE TOP OF A FRAME AT STATION 1134 BY THE APU COMPARTMENT. THE CABLE HAD CUT THROUGH THE FRAME PAST THE L-ANGLE MORE THAN 1/8 INCH DEEP AND THE CABLE WAS STARTING TO FRAY, FAILURE OF THE CABLE OR FARTHER BINDING BY CUTTING INTO THE FRAME COULD HAVE CAUSED COMPLETE LOSS OF THE L-H ELEVATOR. THE ACFT HAD JUST COME OUT OF A HEAVY OVERHAUL BY AN OUTSIDE VENDOR ON JAN-WED-04. THIS IS NOT THE FIRST TIME WE HAVE SEEN SUCH POOR QUALITY WORK COME FROM THESE CONTRACTED OPS AND PROVIDES A PERFECT EXAMPLE OF WHY THESE OPS NEED MUCH GREATER OVERSIGHT BY THE FAA & NTSB. THEY ARE PRODUCING POOR QUALITY WORK WITH DISASTROUS POTENTIAL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED AFTER TROUBLESHOOTING FOR SEVERAL HOURS, THE L ELEVATOR DOWN CABLE WAS FOUND MISROUTED OVER THE TOP OF A FRAME AT STATION 1134 AT THE AUXILIARY POWER UNIT COMPARTMENT. THE RPTR SAID THE CABLE .125 INCH DIAMETER, HAD CUT MORE THAN ONE EIGHTH INCH DEEP INTO THE FRAME AND 'L' ANGLE AND THE CABLE WAS BEGINNING TO FRAY. THE RPTR STATED THE TENSION ON THE CABLE WAS THREE TIMES REQUIRED MAINT MANUAL LIMITS. THE RPTR SAID THE FACT THE TENSION WAS WAY OUT OF LIMITS SHOULD HAVE ALERTED THE PERSONS INSTALLING THE CABLE OF SOMETHING SERIOUSLY WRONG. THE RPTR STATED THIS WAS ONE OF MANY HEAVY MAINT JOBS DONE BY CONTRACT MAINT THAT WAS ACCOMPLISHED WITH POOR QUALITY WORK.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.